Friday, January 16, 2015

Q. On November 21, 2014, HHS clarified that a plan benefit year could begin as late as March31, 2014 for the purpose of establishing member months to meet the credibility thresholdrequired by the cost-sharing reduction reconciliation simplified methodology. Does the newMarch 31, 2014 deadline include people who applied or tried to apply by March 31, 2014, butwhose enrollments were not effectuated?

A: Yes. A Qualified Health Plan issuer assessing whether enrollment meets the credibility
threshold for the simplified methodology may count members who applied or tried to apply by
March 31, 2014, but whose enrollment did not become effective until later because of technology
challenges. This includes members whose applications were not processed until after March 31,
2014, postponing their start date until May, and members who received a special enrollment
period because Exchange issues prevented them from filing an application by March 31, 2014.

The cost-sharing reduction reconciliation simplified methodology provided in 45 CFR
156.430(c)(4) allows issuers to develop a set of effective cost-sharing parameters based on the
average experience of enrollees in a standard plan. HHS in 45 CFR 156.430(c)(4)(v) set a
minimum of 12,000 member months per benefit year in the standard plan to establish a credible
claims data base on which to measure cost-sharing parameters.

Because of 2014 enrollment delays, we will consider this standard met if at least 12,000 member
months are accumulated for enrollees, each of whom applied or tried to apply to the plan
beginning no later than March 31, 2014 and remained in the plan until the end of the benefit year
on December 31, 2014. This includes members who received special enrollment periods that
resulted in an effective date up to but not later than May 31, 2014.

Issuers that selected the simplified methodology but do not meet the foregoing 12,000-member
month credibility standard must use the Actuarial Value simplified methodology described at 45
CFR 156.430 (c)(4) (v).

Friday, January 9, 2015

On November 13, 2014, the Centers for Medicare and Medicaid Services (CMS) issued the Medicare Physician Fee Schedule final rule, including a new code and guidance for billing for chronic care management services (CCM), effective January 1, 2015. The final rule sets forth criteria for submitting claims to Medicare for CCM services and establishes a base reimbursement rate of $42.60 for such services. The provision of coverage for CCM services is an important corollary to the population management goals of accountable care organizations, and is consistent with various incentives established by the Affordable Care Act. While some questions remain unanswered, Medicare reimbursement for CCM services should greatly benefit the growing population of elderly patients with multiple comorbidities, many of whom depend on proactive care management, including remote monitoring, to avoid medical complications, hospitalization and unnecessary readmissions.

The final rule contains a number of criteria for billing CCM services, including the following: (1) over the course of a month, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional must be devoted to provision of the services; (2) the patient must have multiple chronic conditions that are expected to last at least 12 months, or until the death of the patient; (3) the chronic conditions must place the patient at significant risk of death, acute exacerbation/decompensation or functional decline; and (4) a comprehensive care plan must be established, implemented, revised or monitored. CCM services do not have to be provided face-to-face and include overseeing patient self-medication, ensuring receipt of all recommended preventative services, monitoring a patient’s conditions and reviewing data reported about the patient from a remote monitoring device.

Providers who are eligible to bill for CCM services include physicians, nurse practictioners, physician assistants, clinical nurse specialists and midwives. The CCM provider must: (1) use certified electronic health record technology (but need not qualify for meaningful use incentive payments); (2) create and regularly update a comprehensive electronic care plan for the patient that can be accessed by the care team, other providers who care for the patient, and the patient; (3) offer 24 hours per day, seven days per week access to care for chronic care needs; (4) provide continuity of practice and care management; (5) allow patients to communicate with the provider by phone and asynchronous consultation methods; (6) manage transitions of care within the health care system; and (7) coordinate with home and community-based clinical service providers. CMS will pay for only one provider to furnish CCM to the same patient in the same calendar month.

The patient receiving CCM services must be a Medicare beneficiary and must furnish the provider who is billing for the services, with written consent for the receipt of CCM services. The written consent must be documented in a certified electronic health record and must inform the patient of the following: (1) which CCM services are available; (2) how CCM services are accessed; (3) how patient information will be shared among providers and the care team; (4) that cost sharing applies to services even when they are not delivered face-to-face; (5) that consent to CCM services can be revoked by the patient at any time, effective at the end of the calendar month; and (6) that CMS will pay for the services of only one practitioner in each 30-day period.

There are still certain open questions regarding billing for CCM services. CMS has not provided a definitive list of chronic conditions that qualify a patient to receive the services. Similarly, CMS has not provided standards for evaluating how long the conditions are expected to last or whether the conditions place the patient at significant risk of death, acute exacerbation/decompensation or functional decline. Finally, as most patients with multiple chronic conditions have more than one physician but only one provider may bill for CCM services for a patient in a 30-day period, it is unclear how a patient’s providers will determine who will bill for CCM services. Over time, and with the issuance of manual instructions and medical review policies by CMS and its contractors, certain of these issues may be resolved.